<div id="header-enter-your-practice-details">
	<?php include_partial("progress_bar") ?>
	<form id="step-two-form" action="<?php echo url_for('/doctor-register-step-two/' . $doctor->getId()) ?>" method="post">
		<?php echo $form->renderHiddenFields(false) ?>
		<div class="imperative">Please spare a moment and provide us with your practice details below.</div>
		<?php include_partial("common/input_field", array("form" => $form, "field" => "practice_name")) ?>
		<?php include_partial("common/input_field", array("form" => $form, "field" => "practice_number")) ?>
		<?php include_partial("common/input_field", array("form" => $form, "field" => "work_phone")) ?>
		<?php include_partial("common/input_field", array("form" => $form, "field" => "street_address")) ?>
		<?php include_partial("common/input_field", array("form" => $form, "field" => "area")) ?>
		<?php include_partial("common/input_field", array("form" => $form, "field" => "post_code")) ?>
		<?php include_partial("common/select_field", array("form" => $form, "field" => "region_id")) ?>
		<?php include_partial("common/select_field", array("form" => $form, "field" => "city_id")) ?>
		<div  class="imperative">DocPlus requires your mobile phone in order to facilitate tracked appointments with you.</div>
		<?php include_partial("common/input_field", array("form" => $form, "field" => "mobile_phone")) ?>
        <?php include_partial("common/input_field", array("form" => $form, "field" => "send_sms")) ?>
		<div class="row">
			<ul>
				<li>
					<button id="submit-step-two" type="submit" class="blue-button-30">Proceed</button>
				</li>
			</ul>
		</div>
	</form>
</div>